Impact of Treatment Time on the Long-Term Outcome of Stroke Patients Treated With Mechanical Thrombectomy

Almallouhi, Eyad; Kasab, Sami Al; Harvey, Jillian; Reardon, Christopher; Alawieh, Ali; Girotra, Tarun; Aysse, Patricia; Turner, Raymond D; Holmstedt, Christine A

doi:10.1016/j.jstrokecerebrovasdis.2018.09.033

Cited by 19 publications

(13 citation statements)

References 24 publications

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“…4,5 With the expansion of telestroke networks, more hospitals are now capable of administering intravenous recombinant tissue plasminogen activator (tPA). [6][7][8] Under the telestroke system of care, patients presenting to community hospitals (spokes) with stroke-like symptoms are evaluated by a stroke expert for eligibility for tPA, and are then transferred to a thrombectomy-capable center (hub) for mechanical thrombectomy (MT) evaluation if deemed candidates for such treatment. 9 Prior research on ethnic disparities in a telestroke setting is sparse; one study in Texas suggested no differences in access to telestroke, but did not comment on door-to-needle (DTN) times, differences in tPA administration, or MT evaluation.…”

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confidence: 99%

Racial/Ethnic Disparities in Acute Ischemic Stroke Treatment Within a Telestroke Network

Ajinkya

Almallouhi

Turner

et al. 2020

Telemedicine and e-Health

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Background: The growth of telestroke services expanded the reach of acute stroke treatment. However, ethnic disparities in receiving such treatment have not been fully assessed. Materials and Methods: We reviewed prospectively maintained data on patients evaluated through the Medical University of South Carolina telestroke program between January 2016 and November 2018. Outcomes included odds of receiving intravenous recombinant tissue plasminogen activator (tPA), receiving mechanical thrombectomy (MT), and achieving door-to-needle (DTN) time £60 and £45 min among patients receiving tPA. We used logistic regression to analyze the contribution of race/ ethnicity. Results: We included 2,977 patients, of whom 1,093 (36.7%) identified as nonwhite; of these, 1,048 patients (95.9%) identified as black or African American. Significantly more nonwhite patients were seen at a primary stroke center (PSC) (68.4% vs. 52.3% in whites, p < 0.001). However, white patients had significantly higher odds of receiving tPA (odds ratio [OR] 1.47, confidence interval [95% CI] 1.17-1.84). There was no significant difference in receiving MT between races. Among patients receiving tPA, whites had higher odds of DTN £45 min (OR 1.76, 1.20-2.57) and £60 min (OR 1.87, 95% CI 1.31-2.66). Conclusions: White patients had better odds achieving DTN £45 min and DTN £60 min if receiving tPA within a telestroke setting, as well as higher odds of receiving tPA, even after adjustment for comorbidities. This was noted despite white patients having less access to PSCs. However, larger scale studies are needed to further study the impact of ethnic disparities.

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confidence: 99%

Racial/Ethnic Disparities in Acute Ischemic Stroke Treatment Within a Telestroke Network

Ajinkya

Almallouhi

Turner

et al. 2020

Telemedicine and e-Health

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“…Moreover, the DRT reduction was recorded in most subgroups, including both during and outside office hours. The time metrics of EVT were longer outside office hours than during office hours in past reports,24 25 and a systematic protocol reduced DRT but had no effect outside office hours 8 26. Screening of patients by a vascular neurology fellow or attending neurologist both during and outside office hours, along with a step-by-step approach, may facilitate shortening DRT in various scenarios in large hospitals.…”

Section: Discussionmentioning

confidence: 84%

Reducing door-to-reperfusion time in acute stroke endovascular therapy using magnetic resonance imaging as a screening modality

Sakamoto

Suzuki

Abe

et al. 2020

J NeuroIntervent Surg

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BackgroundThe feasibility of performing MRI first for patients with suspected hyperacute stroke in real-world practice has not been fully examined. Moreover, most past studies of reducing door-to-reperfusion time (DRT) in endovascular treatment (EVT) were conducted using CT. The aim of this study was to evaluate the feasibility of an MRI-first policy and to examine the effects of a quality improvement (QI) process for reducing DRT using MRI.MethodsFrom January 2013 to December 2018, consecutive patients with acute stroke who came to hospital directly and were treated with emergent EVT were prospectively enrolled into the present study. In principle, MRI was performed first for patients with suspected acute stroke. A step-by-step QI process for decreasing DRT was adopted during this period. Time metrics for EVT were compared between specific time periods.ResultsA total of 180 patients (71 women; median age 76 years (range 69–64); National Institutes of Health Stroke Scale score 17 (range 10–23)) were included in the present study. More patients in the late phase were managed with the MRI-first policy (p<0.001). DRT (199 min in Phase 1, 135 min in Phase 2, 129 min in Phase 3, and 121 min in Phase 4, p<0.001) was significantly reduced across the phases. The percentage of patients with DRT <120 min increased significantly across time periods (p<0.001). Symptomatic intracerebral hemorrhage did not increase across phases (p=0.575).ConclusionAn MRI-first policy was feasible, and DRT decreased considerably with a step-by-step QI process. This process may be applicable to other hospitals.

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“…1 . Off-hours VKA-ICH patients showed a significant higher National Institutes of Health Stroke Scale (NIHSS), (13 [6-21] vs. 10 [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18]; p < 0.01), a reduced Glasgow Coma Scale-Score (13 [10][11][12][13][14][15] vs. 14 [11][12][13][14][15]; p = 0.01), and a higher rate of intraventricular hemorrhage (447 [44.5%] vs. 108 [38.7%], p < 0.05) compared to on-hour VKA patients (Table 1). There was no difference regarding the time from symptom onset to hospital admission between on-and offhour VKA patients (98 min [60-266 min] vs. 101 min [60-260 min]; p = 0.97).…”

Section: Off-hour Admission and Baseline Characteristics For Vka-and mentioning

confidence: 99%

“…Previous studies in ischemic stroke reported an "off-hour effect" with increased rates of mortality and poor functional outcome of patients admitted outside regular working hours [8,9]. Specifically, in patients undergoing endovascular treatment, this aspect may be more pronounced [10,11]. It is essentially unestablished whether the efficiency of BP reduction and anticoagulation reversal management differs between on-vs. off-hour admissions in oral anticoagulation (OAC-) associated ICH.…”

Section: Introductionmentioning

confidence: 99%

Blood Pressure and Anticoagulation Reversal Management during Off-Hours in Oral Anticoagulation-Associated Intracerebral Hemorrhage

et al. 2020

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Background: Prevention of hematoma enlargement in oral anticoagulation-associated intracerebral hemorrhage (OAC-ICH) focuses on blood pressure (BP) reduction and OAC reversal. We investigated whether treatment efficiency and clinical outcomes differ between OAC-ICH patients admitted outside versus during regular working hours. Methods: Based on pooled data of multicenter cohort studies, we grouped OAC-ICH patients (vitamin K antagonist [VKA], nonvitamin K oral anticoagulant [NOAC]) according to on-vs. offhour admission. Primary outcome was the functional outcome using the modified Rankin scale (mRS) dichotomized into favorable (mRS 0-3) and unfavorable (mRS 4-6) and mortality at 3 months. Secondary outcome measures included the occurrence of hematoma enlargement, the proportions of patients with systolic BP <140 mm Hg and with anticoagulation treatment achieving international normalized ratio (INR) levels <1.3 at 4 h. Propensity score matching (PSM) was performed to account for imbalances in baseline characteristics. Results: The study population consisted of 76/126 NOAC-ICH patients and 1,005/1,470 VKA patients presenting during off-hours. Functional outcome and mortality rates were not significantly different among PSM patients with VKA-ICH and NOAC-ICH during on-vs. off-hours (mRS 4-6 VKA-ICH: on-hour: 239/357 [66.9%] vs. 253/363 [69.7%] off-hour; p = 0.43; NOAC-ICH: on-hour 26/42 [61.9%] vs. offhour: 37/57 [64.9%]; p = 0.76; mRS 6 VKA-ICH: on-hour: 127/357 [35.6%] vs. off-hour: 148/363 [40.8%]; p = 0.15; NOAC-ICH: on-hour 17/42 [40.5%] vs. off-hour: 16/57 [28.1%]; p = 0.20). There were no differences detectable regarding the secondary outcome measures (i.e., hematoma enlargement, the proportion of patients who achieved systolic BP levels <140 mm Hg at 4 h as well as anticoagulation treatment achieving INR levels < 1.3 at 4 h) in OAC patients. Conclusion:Our study implies that BP reduction and anticoagulation reversal management are well established and associated with similar rates of hematoma enlargement and clinical outcomes in on-vs. off-hour admitted OAC-ICH patients.

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Impact of Treatment Time on the Long-Term Outcome of Stroke Patients Treated With Mechanical Thrombectomy

Cited by 19 publications

References 24 publications

Racial/Ethnic Disparities in Acute Ischemic Stroke Treatment Within a Telestroke Network

Racial/Ethnic Disparities in Acute Ischemic Stroke Treatment Within a Telestroke Network

Reducing door-to-reperfusion time in acute stroke endovascular therapy using magnetic resonance imaging as a screening modality

Blood Pressure and Anticoagulation Reversal Management during Off-Hours in Oral Anticoagulation-Associated Intracerebral Hemorrhage

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